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Laber DA, Patel PC, Logothetis CN, Patel AK, Jaglal M, Haider M, Visweshwar N, Rajasekaran-Rathnakumar G, Eatrides J. Complement-mediated thrombotic microangiopathy treated with anticomplement protein 5 therapy, a retrospective study. Eur J Haematol 2024; 112:450-457. [PMID: 37984551 PMCID: PMC11351077 DOI: 10.1111/ejh.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Complement-mediated thrombotic microangiopathy (CM-TMA), also called atypical hemolytic uremic syndrome (aHUS), is a difficult-to-diagnose rare disease that carries severe morbidity and mortality. Anti-C5 monoclonal antibodies (aC5-mab) are standard treatments, but large studies and long-term data are scarce. Here, we report our single institution experience to augment the knowledge of CM-TMA treated with aC5-mab therapy. METHODS We aimed to assess the short and long-term effects of aC5-mab in patients diagnosed with CM-TMA treated outside of a clinical trial. This was a retrospective study. We included all patients diagnosed with CM-TMA and treated with aC5-mab at our institution. There were no exclusion criteria. Endpoints included complete TMA response (CR) defined as normalization of hematological parameters and ≥25% improvement in serum creatinine (Cr) from baseline in patients with renal disease, relapse defined as losing the previously achieved CR, morbidity, adverse events, and survival. RESULTS We found 28 patients with CM-TMA treated with aC5-mab. The median age was 50 years. Baseline laboratories: platelet counts 93 × 109 /L, hemoglobin 8.6 g/dL, lactate dehydrogenase 1326 U/L, serum Cr 4.7 mg/dL, and estimated glomerular filtration rate 19 mL/min. One individual was on renal replacement therapy (RRT) and 10 initiated RRT within 5 days of the first dose of aC5-mab. Genetic variants associated with CM-TMA included mutations in C3, CFB, CFH, CFHR1/3, CFI, and MCP. The mean duration of hospitalization was 24 days. The median time to initiation of aC5-mab was 10 days. Sixteen subjects received RRT. At the time of hospital discharge, 27 were alive, 14 remained on RRT, and 4 had a CR. At 6 months, 23 patients were alive, 18 continued aC5-mab, 8 remained on RRT, and 9 had a CR. At the last follow-up visit past 6 months, 20 were alive, 14 continued aC5-mab, 5 remained on RRT, 12 had a CR, and 1 was lost to follow-up. CONCLUSIONS Our study provides real-world experience and insight into the long-term outcomes of CM-TMA treated with aC5-mab. Our findings validate that CM-TMA is an aggressive disease with significant morbidity and mortality, and confirm that aC5-mab is a relatively effective therapy for CM-TMA. Our study adds practical, real-world experience to the literature, but future research remains imperative.
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Affiliation(s)
- Damian A. Laber
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Parth C. Patel
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Ankita K. Patel
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael Jaglal
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mintallah Haider
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Nathan Visweshwar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Geetha Rajasekaran-Rathnakumar
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jennifer Eatrides
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Complement gene variant effect on relapse of complement-mediated thrombotic microangiopathy after eculizumab cessation. Blood Adv 2022; 7:340-350. [PMID: 35533258 PMCID: PMC9881046 DOI: 10.1182/bloodadvances.2021006416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Eculizumab is effective for complement-mediated thrombotic microangiopathy (CM-TMA), also known as atypical hemolytic uremic syndrome. Although lifelong therapy had been suggested, discontinuation does not universally lead to relapse. Comprehensive data evaluating risk factors for recurrence following discontinuation are limited. Our aim was to systematically review available literature assessing the role of complement genetic variants in this setting. Reports on CM-TMA and eculizumab withdrawal published before 1 January 2021, were included. Key reasons for patient exclusion were no follow-up after drug withdrawal and patients lacking complement genetic testing. Two-hundred eighty patients from 40 publications were included. Median age was 28 years, and 25 patients had a known history of renal transplant. Complement genetic variants were identified in 60%, most commonly in CFH (n = 59) and MCP/CD46 (n = 38). Of patients with a complement gene variant, 51.3% had ≥1 likely pathogenic/pathogenic variant whereas the remaining had variants of uncertain significance (VUS). Overall relapse rate after therapy discontinuation was 29.6%. Relapse rate was highest among patients with CFH variants and MCP/CD46 variants in canonical splice regions. VUS (P < .001) and likely pathogenic/pathogenic variants (P < .001) were associated with increased relapse. Presence of a renal allograft (P = .009); decreasing age (P = .029); and detection of variants in CFH (P < .001), MCP/CD46 (P < .001), or C3 (P < .001) were all independently associated with relapse after eculizumab discontinuation. Eculizumab discontinuation is appropriate in specific patients with CM-TMA. Caution should be exerted when attempting such a strategy in patients with high risk of recurrence, including a subgroup of patients with MCP/CD46 variants.
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Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single-center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Abstract
Our case series showed that eculizumab is efficacious and safe in treating thrombotic microangiopathy, as well as it has positive effects on quality of life. Further extensive studies are required to develop unified treatment guidelines.
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Affiliation(s)
| | - Artūras Vinikovas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Marius Miglinas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Laurynas Rimševičius
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Agnė Čerkauskaitė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Ernesta Mačionienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Eglė Ašakienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
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Jiao L, Li H, Guo S. Eculizumab treatment for myasthenia gravis subgroups: 2021 update. J Neuroimmunol 2022; 362:577767. [PMID: 34823117 DOI: 10.1016/j.jneuroim.2021.577767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 11/01/2021] [Accepted: 11/13/2021] [Indexed: 01/21/2023]
Abstract
Eculizumab is a recombinant humanized monoclonal antibody that targets the complement protein C5, inhibiting its cleavage into C5a and C5b and ultimately preventing the formation of C5b-9 membrane attack complex (MACs), thereby protecting the neuromuscular junction from the damage of complement activation. In 2017, eculizumab became the second FDA-approved medication for AchR-positive generalized myasthenia gravis (gMG) patients based on the successful results of a randomized, double-blinded, placebo-controlled, phase 2, phase 3 study (the REGAIN trial) and its open-label extension study. Despite the efficacy of eculizumab in treating AchR antibody-positive refractory gMG was demonstrated in the REGAIN study, there is few information on its efficacy in other subgroup of MG patients including seronegative MG, thymoma-associated MG and MG crisis. This narrative review summarizes current clinical studies of eculizumab in these refractory gMG patients, with a focus on the therapeutic efficacy and tolerability in different subgroup of MG.
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Affiliation(s)
- Li Jiao
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jing Wu Road, Huaiyin District, Jinan 250021, Shandong, China
| | - Honghao Li
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jing Wu Road, Huaiyin District, Jinan 250021, Shandong, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jing Wu Road, Huaiyin District, Jinan 250021, Shandong, China.
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Brambilla M, Ardissino G, Paglialonga F, Testa S, Capone V, Montini G. Haemoglobinuria for the early identification of aHUS relapse: data from the ItalKId-HUS Network. J Nephrol 2021; 35:279-284. [PMID: 33459950 DOI: 10.1007/s40620-021-00965-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Atypical haemolytic uremic syndrome (aHUS) is at high risk of relapse at any time, therefore patients require lifelong monitoring. The most appropriate way to monitor patients is not yet clear. Patients could be monitored for relapse by urine dipstick testing for haemoglobinuria based on the hypothesis that thrombotic microangiopathy involving the glomerulus and associated with renal damage (like aHUS) cannot occur without haematuria. METHODS The aim of this retrospective study is to analyse our experience with this approach in aHUS patients who have never previously been treated, who are currently on treatment or who have discontinued C5 inhibition. The records of all aHUS patients (children and adults) managed by or referred to our Centre from January 2009 to March 2020 were included and the analysis for the presence of haemoglobinuria was restricted to the period following primary remission. A positive test was defined as haemoglobin ≥ 1 + . Patients reporting positive urine dipstick tests underwent laboratory investigations to rule in or out the diagnosis of aHUS relapse. RESULTS Eighty-four patients were included with 1517 determinations of haemoglobinuria during a cumulative observation period of 8904 patient-months. Haemoglobinuria for the early diagnosis of ongoing aHUS relapse shows a sensitivity of 100% and a specificity of 87.4% with a positive predictive value (PPV) of 10.5% and a negative predictive value (NPV) of 100%. The accuracy of the test was 87.6%. CONCLUSION Haemoglobinuria is a very sensitive and acceptably specific marker of aHUS relapse. This finding and its validation may have a positive impact on patients' quality of life and on the outcome of this life threatening disease via early diagnosis of relapse.
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Affiliation(s)
- Marta Brambilla
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.
| | - Gianluigi Ardissino
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Fabio Paglialonga
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Sara Testa
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Valentina Capone
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Giovanni Montini
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.,Giuliana and Bernardo Caprotti, Chairs of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Different approaches to long-term treatment of aHUS due to MCP mutations: a multicenter analysis. Pediatr Nephrol 2021; 36:463-471. [PMID: 32715379 PMCID: PMC7815604 DOI: 10.1007/s00467-020-04714-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening microangiopathy, frequently causing kidney failure. Inhibition of the terminal complement complex with eculizumab is the only licensed treatment but mostly requires long-term administration and risks severe side effects. The underlying genetic cause of aHUS is thought to influence the severity of initial and recurring episodes, with milder courses in patients with mutations in membrane cofactor protein (MCP). METHODS Twenty pediatric cases of aHUS due to isolated heterozygous MCP mutations were reported from 12 German pediatric nephrology centers to describe initial presentation, timing of relapses, treatment, and kidney outcome. RESULTS The median age of onset was 4.6 years, with a female to male ratio of 1:3. Without eculizumab maintenance therapy, 50% (9/18) of the patients experienced a first relapse after a median period of 3.8 years. Kaplan-Meier analysis showed a relapse-free survival of 93% at 1 year. Four patients received eculizumab long-term treatment, while 3 patients received short courses. We could not show a benefit from complement blockade therapy on long term kidney function, independent of short-term or long-term treatment. To prevent 1 relapse with eculizumab, the theoretical number-needed-to-treat (NNT) was 15 for the first year and 3 for the first 5 years after initial presentation. CONCLUSION Our study shows that heterozygous MCP mutations cause aHUS with a risk of first relapse of about 10% per year, resulting in large NNTs for prevention of relapses with eculizumab. More studies are needed to define an optimal treatment schedule for patients with MCP mutations to minimize the risks of the disease and treatment.
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Fayek SA, Allam SR, Martinez E, Pan G, Dao A, Rofaiel G. Atypical Hemolytic Uremic Syndrome After Kidney Transplantation: Lessons Learned From the Good, the Bad, and the Ugly. A Case Series With Literature Review. Transplant Proc 2020; 52:146-152. [PMID: 31924403 DOI: 10.1016/j.transproceed.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) after kidney transplantation is rare and carries a grave outcome. We present a single-center experience of all aHUS cases since the program's inception. Six patients were diagnosed with aHUS, all after kidney transplants, except for 1 patient. All had nonreactive crossmatches. Delayed graft function (DGF) occurred in 2 patients. Five patients developed aHUS after transplant; 4 (80%) of these patients manifested aHUS ≤ 14 days. All were confirmed by allograft biopsy. Genetic testing was abnormal in all patients except for 1 patient. Actual patient and graft survival during the first year was 100% and 83.3%, respectively. A single graft was lost early in the study secondary to aHUS (eculizumab was not used in the treatment process). Prophylactic and therapeutic use of eculizumab salvaged all other cases. At 1 year, mean creatinine level was 1.9 mg/dL (range, 1.3-2.5). After 6 months of eculizumab treatment (halted in 2 cases) 1 patient had recurrence 2 months later and eculizumab was restarted. However, graft function continued to worsen, and the graft was ultimately lost at 20 months after kidney transplantation. High index of suspicion, prompt diagnosis, and utilization of eculizumab are key to successful salvage of allografts in cases of aHUS after kidney transplantation. aHUS can be prevented by prophylactic use of eculizumab. It still needs to be determined when and if eculizumab therapy can be safely discontinued.
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Affiliation(s)
- Sameh A Fayek
- Department of Surgery, Section of Abdominal Transplantation, Inova Fairfax Medical Campus, Falls Church, VA, Unites States; Department of Surgery, Faculty of Medicine, Cairo University, Egypt.
| | - Sridhar R Allam
- Department of Transplantation, Medical City Fort Worth, Fort Worth, Texas, United States
| | - Eryberto Martinez
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Gilbert Pan
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Ann Dao
- Department of Transplantation, Medical City Fort Worth, Fort Worth, Texas, United States
| | - George Rofaiel
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
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García-Martín E, Manrique-Rodríguez S, Martínez Fernández-Llamazares C, Goicoechea-Diezhondino M, Álvarez-Blanco O, García-Morín M, Sanjurjo-Sáez M. Variability in management and outcomes of therapy with eculizumab in atypical hemolytic uremic syndrome. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1703108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Estela García-Martín
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - Marian Goicoechea-Diezhondino
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Olalla Álvarez-Blanco
- Pediatric Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marina García-Morín
- Pediatric Oncohematology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - María Sanjurjo-Sáez
- Director of Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
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Higuero Saavedra V, González-Calle V, Sobejano E, Sebastiá J, Cabrero M, Bastida JM, Puig N, Ocio EM, Mateos MV. Drug-induced Thrombotic Microangiopathy During Maintenance Treatment in a Patient With Multiple Myeloma. Hemasphere 2019; 3:e192. [PMID: 31723829 PMCID: PMC6746023 DOI: 10.1097/hs9.0000000000000192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023] Open
Affiliation(s)
- Víctor Higuero Saavedra
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Verónica González-Calle
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Eduardo Sobejano
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Josefa Sebastiá
- Nephrology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Mónica Cabrero
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Jose María Bastida
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Noemi Puig
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Enrique M. Ocio
- Hematology Department, Hospital Universitario Marqués de Valdecilla
| | - María-Victoria Mateos
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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Harris CL, Pouw RB, Kavanagh D, Sun R, Ricklin D. Developments in anti-complement therapy; from disease to clinical trial. Mol Immunol 2018; 102:89-119. [PMID: 30121124 DOI: 10.1016/j.molimm.2018.06.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 02/06/2023]
Abstract
The complement system is well known for its role in innate immunity and in maintenance of tissue homeostasis, providing a first line of defence against infection and playing a key role in flagging apoptotic cells and debris for disposal. Unfortunately complement also contributes to pathogenesis of a number of diseases; in some cases driving pathology, and in others amplifying or exacerbating the inflammatory and damaging impact of non-complement disease triggers. The role of complement in pathogenesis of an expanding number of diseases has driven industry and academia alike to develop an impressive arsenal of anti-complement drugs which target different proteins and functions of the complement cascade. Evidence from genetic and biochemical analyses, combined with improved identification of complement biomarkers and supportive data from sophisticated animal models of disease, has driven a drug development landscape in which the indications selected for clinical trial cluster in three 'target' tissues: the kidney, eye and vasculature. While the disease triggers may differ, complement activation and amplification is a common feature in many diseases which affect these three tissues. An abundance of drugs are in clinical development, some show favourable progression whereas others experience significant challenges. However, these hurdles in themselves drive an ever-evolving portfolio of 'next-generation' drugs with improved pharmacokinetic and pharmacodynamics properties. In this review we discuss the indications which are in the drug development 'spotlight' and review the relevant indication validation criteria. We present current progress in clinical trials, highlighting successes and difficulties, and look forward to approval of a wide selection of drugs for use in man which give clinicians choice in mechanistic target, modality and route of delivery.
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Affiliation(s)
- Claire L Harris
- Complement Therapeutics Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
| | - Richard B Pouw
- Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, CH-4056, Basel, Switzerland
| | - David Kavanagh
- Complement Therapeutics Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Ruyue Sun
- Complement Therapeutics Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Daniel Ricklin
- Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, CH-4056, Basel, Switzerland.
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Atypical hemolytic uremic syndrome: Review of clinical presentation, diagnosis and management. J Immunol Methods 2018; 461:15-22. [PMID: 30031798 DOI: 10.1016/j.jim.2018.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thrombotic microangiopathies (TMA) are a class of disorders characterized by microangiopathic hemolytic anemia, non-immune thrombocytopenia, and organ dysfunction. One type of TMA is atypical hemolytic uremic syndrome (aHUS) a disorder caused by hyper-activation of the alternative complement pathway due to over activation of C3 convertases and loss of complement regulatory mechanisms. The pathophysiological mechanism of aHUS involves increased continuous spontaneous hydrolysis of C3 to C3b which leads to tissue deposition of C3b, the membrane attack complex formation and subsequent tissue injury. The underlying susceptibility factors to aHUS include acquired autoantibodies or germline mutations in complement proteins or their regulators. Currently there are no clear diagnostic criteria for aHUS. Diagnosis involves ruling out other causes of TMA and incorporating complement serologic and genetic data. TPE has been used to treat aHUS; however, clinical improvement in these patents is far less than in patients with thrombotic thrombocytopenic purpura. Furthermore, there is a higher rate of progression to end stage renal disease with almost half of patients progressing despite TPE. For those, another option for treatment is eculizumab, a monoclonal antibody that blocks complement C5. Eculizumab has proven effective in aHUS and dramatically changed the prognosis of this syndrome. In this review the clinical presentation, diagnosis and management of aHUS are highlighted with three clinical cases.
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Kim SH, Kim HY, Kim SY. Atypical hemolytic uremic syndrome and eculizumab therapy in children. KOREAN JOURNAL OF PEDIATRICS 2018; 61:37-42. [PMID: 29563942 PMCID: PMC5854840 DOI: 10.3345/kjp.2018.61.2.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/16/2018] [Accepted: 01/25/2018] [Indexed: 01/30/2023]
Abstract
Hemolytic uremic syndrome (HUS) is often encountered in children with acute kidney injury. Besides the well-known shiga toxin-producing Escherichia coli-associated HUS, atypical HUS (aHUS) caused by genetic complement dysregulation has been studied recently. aHUS is a rare, chronic, and devastating disorder that progressively damages systemic organs, resulting in stroke, end-stage renal disease, and death. The traditional treatment for aHUS is mainly plasmapheresis or plasma infusion; however, many children with aHUS will progress to chronic kidney disease despite plasma therapy. Eculizumab is a newly developed biologic that blocks the terminal complement pathway and has been successfully used in the treatment of aHUS. Currently, several guidelines for aHUS, including the Korean guideline, recommend eculizumab as the first-line therapy in children with aHUS. Moreover, life-long eculizumab therapy is generally recommended. Further studies on discontinuation of eculizumab are needed.
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Affiliation(s)
- Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Hye Young Kim
- Department of Pediatrics, Pusan National University Hospital, Busan, Korea
| | - Su Young Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
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Abstract
The increasing number of clinical conditions that involve a pathological contribution from the complement system - many of which affect the kidneys - has spurred a regained interest in therapeutic options to modulate this host defence pathway. Molecular insight, technological advances, and the first decade of clinical experience with the complement-specific drug eculizumab, have contributed to a growing confidence in therapeutic complement inhibition. More than 20 candidate drugs that target various stages of the complement cascade are currently being evaluated in clinical trials, and additional agents are in preclinical development. Such diversity is clearly needed in view of the complex and distinct involvement of complement in a wide range of clinical conditions, including rare kidney disorders, transplant rejection and haemodialysis-induced inflammation. The existing drugs cannot be applied to all complement-driven diseases, and each indication has to be assessed individually. Alongside considerations concerning optimal points of intervention and economic factors, patient stratification will become essential to identify the best complement-specific therapy for each individual patient. This Review provides an overview of the therapeutic concepts, targets and candidate drugs, summarizes insights from clinical trials, and reflects on existing challenges for the development of complement therapeutics for kidney diseases and beyond.
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Affiliation(s)
- Daniel Ricklin
- Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland
| | - Dimitrios C Mastellos
- National Center for Scientific Research 'Demokritos', Patr. Gregoriou E & 27 Neapoleos Str, 15341 Agia Paraskevi, Athens, Greece
| | - Edimara S Reis
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, 401 Stellar Chance, 422 Curie Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, 401 Stellar Chance, 422 Curie Boulevard, Philadelphia, Pennsylvania 19104, USA
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Neumann T, Plis A, Weigel M, Stracke S, Friesecke S, Stecher SS, Schneidewind L, Busemann C, Schmidt CA, Krüger WH. No Relapse of Calcineurin Inhibitor-Associated Thrombotic Microangiopathy after Discontinuation of Eculizumab. Acta Haematol 2017; 138:194-197. [PMID: 29136616 DOI: 10.1159/000481724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Thomas Neumann
- Department of Internal Medicine C (Haematology and Oncology, Stem Cell Transplantation, Palliative Care), University Hospital Greifswald, Ernst-Moritz-Arndt University, Greifswald, Germany
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury. The histopathologic lesions of aHUS include thrombotic microangiopathy involving the glomerular capillaries and thrombosis involving arterioles or interlobar arteries. Extra-renal manifestations occur in up to 20% of patients. The majority of aHUS is caused by complement system defects impairing ordinary regulatory mechanisms. Activating events therefore lead to unbridled, ongoing complement activity producing widespread endothelial injury. Pathologic mutations include those resulting in loss-of-function in a complement regulatory gene (CFH, CFI, CD46 or THBD) or gain-of-function in an effector gene (CFB or C3). Treatment with the late complement inhibitor, eculizumab – a monoclonal antibody directed against C5 – is effective.
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Affiliation(s)
- Kuixing Zhang
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Yuxin Lu
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Kevin T Harley
- Department of Internal Medicine, Division of Nephrology and Hypertension, Irvine School of Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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Schubert J, Menne J. Eculizumab for the treatment of hemolytic paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome and refractory myasthenia gravis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1307104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jörg Schubert
- Department of Hematology, Oncology and Gastroenterology, Elblandklinikum Riesa, Riesa, Germany
| | - Jan Menne
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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Abstract
The complement system is an essential part of the innate immune system that requires careful regulation to ensure responses are appropriately directed against harmful pathogens, while preventing collateral damage to normal host cells and tissues. While deficiency in some components of the complement pathway is associated with increased susceptibility to certain infections, it has also become clear that inappropriate activation of complement is an important contributor to human disease. A number of hematologic disorders are driven by complement, and these disorders may be termed "complementopathies". This includes paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), cold agglutinin disease (CAD) and other related disorders, which will be the focus of this review. A better understanding of the central role of the complement system in the pathophysiology of these disorders may allow for application of therapies directed at blocking the complement cascade.
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Affiliation(s)
- Andrea C Baines
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA.
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA.
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